The Farr Institute of Health Informatics Research, London, UK; Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK.
Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK; Children's Policy Research Unit, UCL Great Ormond Street Institute of Child Health, London, UK.
Lancet. 2018 May 19;391(10134):2008-2018. doi: 10.1016/S0140-6736(18)30670-6. Epub 2018 May 3.
Child mortality is almost twice as high in England compared with Sweden. We aimed to establish the extent to which adverse birth characteristics and socioeconomic factors explain this difference.
We developed nationally representative cohorts of singleton livebirths between Jan 1, 2003, and Dec 31, 2012, using the Hospital Episode Statistics in England, and the Swedish Medical Birth Register in Sweden, with longitudinal follow-up from linked hospital admissions and mortality records. We analysed mortality as the outcome, based on deaths from any cause at age 2-27 days, 28-364 days, and 1-4 years. We fitted Cox proportional hazard regression models to estimate the hazard ratios (HRs) for England compared with Sweden in all three age groups. The models were adjusted for birth characteristics (gestational age, birthweight, sex, and congenital anomalies), and for socioeconomic factors (maternal age and socioeconomic status).
The English cohort comprised 3 932 886 births and 11 392 deaths and the Swedish cohort comprised 1 013 360 births and 1927 deaths. The unadjusted HRs for England compared with Sweden were 1·66 (95% CI 1·53-1·81) at 2-27 days, 1·59 (1·47-1·71) at 28-364 days, and 1·27 (1·15-1·40) at 1-4 years. At 2-27 days, 77% of the excess risk of death in England was explained by birth characteristics and a further 3% by socioeconomic factors. At 28-364 days, 68% of the excess risk of death in England was explained by birth characteristics and a further 11% by socioeconomic factors. At 1-4 years, the adjusted HR did not indicate a significant difference between countries.
Excess child mortality in England compared with Sweden was largely explained by the unfavourable distribution of birth characteristics in England. Socioeconomic factors contributed to these differences through associations with adverse birth characteristics and increased mortality after 1 month of age. Policies to reduce child mortality in England could have most impact by reducing adverse birth characteristics through improving the health of women before and during pregnancy and reducing socioeconomic disadvantage.
The Farr Institute of Health Informatics Research (through the Medical Research Council, Arthritis Research UK, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Economic and Social Research Council, Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institute for Social Care and Health Research, and the Wellcome Trust).
英格兰的儿童死亡率几乎是瑞典的两倍。我们旨在确定不良出生特征和社会经济因素在多大程度上解释了这种差异。
我们使用英格兰的医院住院统计数据和瑞典的瑞典医疗出生登记处，在 2003 年 1 月 1 日至 2012 年 12 月 31 日期间，开发了具有全国代表性的单胎活产队列，并进行了纵向随访，随访内容包括医院就诊和死亡记录。我们将死亡作为结果，基于出生后 2-27 天、28-364 天和 1-4 岁时的任何原因死亡。我们使用 Cox 比例风险回归模型来估计英格兰与瑞典在所有三个年龄组中的风险比（HR）。模型调整了出生特征（胎龄、出生体重、性别和先天性异常）和社会经济因素（母亲年龄和社会经济地位）。
英格兰队列包括 3932886 例分娩和 11392 例死亡，瑞典队列包括 1013360 例分娩和 1927 例死亡。调整后，英格兰与瑞典相比的 HR 分别为 2-27 天时为 1.66（95%CI 1.53-1.81），28-364 天时为 1.59（1.47-1.71），1-4 岁时为 1.27（1.15-1.40）。在 2-27 天内，英格兰死亡风险的超额风险中有 77%可以通过出生特征来解释，另外 3%可以通过社会经济因素来解释。在 28-364 天内，英格兰死亡风险的超额风险中有 68%可以通过出生特征来解释，另外 11%可以通过社会经济因素来解释。在 1-4 岁时，调整后的 HR 并未表明两国之间存在显著差异。
与瑞典相比，英格兰儿童死亡率过高主要是由于英格兰出生特征的不利分布所致。社会经济因素通过与不良出生特征的关联以及增加 1 个月后儿童的死亡率，对这些差异产生了影响。在英格兰，通过改善妇女怀孕前后的健康状况以及减少社会经济劣势，减少儿童死亡率的政策可以通过减少不良出生特征而产生最大影响。
法尔研究所健康信息学研究（通过医学研究理事会、关节炎研究英国、英国心脏基金会、癌症研究英国、首席科学家办公室、经济和社会研究理事会、工程和物理科学研究理事会、国家卫生研究院、国家社会护理和健康研究所以及惠康信托基金会）。
